Provider Demographics
NPI:1750970794
Name:STOUT, JENNIFER D
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:D
Last Name:STOUT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 ER SLAY RD
Mailing Address - Street 2:
Mailing Address - City:DEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71328-9213
Mailing Address - Country:US
Mailing Address - Phone:318-452-8200
Mailing Address - Fax:
Practice Address - Street 1:1515 LA 107
Practice Address - Street 2:
Practice Address - City:CENTER POINT
Practice Address - State:LA
Practice Address - Zip Code:71323
Practice Address - Country:US
Practice Address - Phone:318-452-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-14
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200117225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA200117OtherOCCUPATIONAL THERAPY LICENSE NUMBER